Confidential Initial Case Management Conference …

1 Confidential Initial case Management Conference Data SheetSTATE OF minnesota COUNTY OF:IN DISTRICT COURT JUDICIAL DISTRICT File No. Confidential Initial case Management Conference Data FORM MUST BE COMPLETED WITH THE BEST INFORMATION AVAILABLE AT THE TIME OF COMPLETION AND SUBMITTED TO THE COURT AT LEAST TWO BUSINESS DAYS BEFORE THE Initial case Management Conference . 1. Is an interpreter needed for the ICMC? 2. The following information is provided by the . 3. a. Has either party been the subject of a harassment restraining order? b. Has either party been the subject of a domestic abuse order for protection? c. Has domestic abuse occurred in this relationship? INFORMATION REGARDING CHILDREN: 1.

2 List the names, birthdays, and ages of the minor children in this relationship. 2. List the names, birthdays, and ages of other minor children of the parties. 3. Have any of the children been the subject of a child protection case ? If yes, when , where . 4. Is there an agreement regarding legal custody of the children? 5. Is there an agreement regarding physical custody of the children? 6. Is there an agreement regarding parenting time? 7. Give a statement of what the agreement is for each issue that is resolved: (attach additional pages as required.) INFORMATION REGARDING ALTERNATIVE DISPUTE RESOLUTION OPTIONS: (Check One) Mediation Parties agree to retain the services of and will pay all costs.

3 Early Neutral Evaluation Parties agree to participate in court annexed ENE program for a set fee. Parties agree to participate in a private ENE program and pay all costs. Other (please indicate) INFORMATION REGARDING FINANCES 1. Names and Addresses 2. Petitioner's gross monthly income: Respondent's gross monthly income: Petitioner's Employer and Address:Respondent's Employer and Address: 3. Summary of monthly budget expenses (for the party preparing this form): ExpensesAmount Mortgage Rent Food Telephone Heat Sewer/Water/Garbage Electricity Cable TV/Internet Medical Expenses Health/Life Insurance Home Insurance Car Insurance Car Payment Car Repair/Fuel Daycare School Expenses DonationsLoansAmountCredit Card Bills (itemize) AmountOther (itemize)Amount4.

4 Homestead AddressHomestead ExpensesAmountApproximate Household ValueMortgage on HomesteadDate of PurchaseBank NameBalance (Checking/Savings) List balances separately5. Checking Accounts and Balances:6. Pensions and Profit Sharing Plans (specify account name, approximate value, how it is owned and by whom):7. Automobiles (make, model, year, approximate mileage, and approximate value):8. Recreational equipment (boats, guns, ATV, motorcycles, etc.) (Include make, mode, year, approximate value):9. Other Assets of Value (Do not include normal household goods and furnishings). List each with an approximate value:10. Are there non-marital claims? If yes, please itemize:ATTACH THE FOLLOWING DOCUMENTS TO THIS DATA SHEET: 1. Pay stubs for the last three months of employment 2.

5 Please attach your most recent Federal Tax Return with all attachments, including W-2s and 1099's as applicable. 3. Please attach any unemployment compensation statements or worker's compensation statements and all other income received during the last three months, including any public financial assistance in money or in-kind services (grants, heating assistance, medical assistance, etc.) THIS FORM WAS PREPARED BY: Address/Telephone Number/Date:PrintSignatur